Appeals & Grievances Clinical Specialist

HealthFirst•Remote - NY, ND

6d•$73,400 - $120,360•Remote

About The Position

The Appeals & Grievances Clinical Specialist is responsible for receiving, investigating and responding verbally and in writing to member and provider clinical appeals and grievances. Healthfirst is New York's largest not-for-profit health insurer offering its nearly 1.7 million members access to high-quality, affordable healthcare. As part of the community for nearly 30 years, Healthfirst's unique advantage is rooted in its belief that good health doesn’t start in a doctor’s office. The company’s mission is to put its members first by working closely with care providers and community leaders to address broader issues that can impact health and well-being. This value-based care model is the foundation of the company’s sustained growth in one of the most dynamic markets in the country.

Requirements

LPN or RN
Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system. (ie. Macess).
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Nice To Haves

Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
Understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual or Medicare Guidelines.

Responsibilities

Ensures that appeals and grievances are properly classified (e.g. denial of service, denial of payment, or a grievance about a provider)
Processes appeals and grievances in accordance with internal company policy
Enters data into appropriate medical management services
Collaborates with other departments to thoroughly investigate appeal and grievances.
Prepares for and participates in regulatory site visits.
Additional duties as assigned.